MHA Today | April 27, 2018

April 27, 2018

April 27, 2018

MHA Today is provided as a service to members of the Missouri Hospital Association. Additional information is available online at MHAnet.

Insights

Missouri’s Division of Professional Registration licenses barbers, embalmers, land surveyors and tattoo artists, in addition to a variety of health professionals. Nowhere on the list is there a profession of self-evaluating emergency diagnostician. Generally, diagnosing a health condition, especially in an emergency, is left to a health professional among those on the list at the Missouri Board of Registration for the Healing Arts. These are the folks who have trained professionally to evaluate and treat health conditions, and have the tools to determine diagnosis from symptoms.

Anthem, a major insurer in Missouri, is second-guessing this system. Anthem’s policy for emergency department coverage determination has been increasingly based on an individual’s diagnosis after an evaluation by a medical professional, rather than the symptoms apparent when an individual presents at a hospital. This has led to some interesting denials. For example, patients have been rejected when: sent to the hospital after passing out at an urgent care center; presenting with severe pain on the right side of the abdomen — a symptom of appendicitis; heart attack symptoms; and after being struck by a car.

This week, lawmakers adopted a bill to strengthen the “prudent layperson” standard that governs emergency coverage in Missouri statutes. By a vote of 31 to one, the Senate approved Senate Bill 982 and sent the bill to the House. The MHA-supported legislation seeks to clarify how the prudent layperson law applies to insurers’ coverage restrictions on hospital ED services.

Anthem’s system is dangerous to patients and is counter to advice offered for decades by organizations like the American Heart Association. In addition, the list of conditions Anthem is flagging for possible review are adversely weighted toward women and minorities. Hospital Industry Data Institute research shows that had the Anthem policy been in place in 2016 (the last year with all hospital discharge data), we would have witnessed the following: 61 percent of claims denied would be for female patients (female-specific diagnosis codes accounted for 10.5 percent of all deniable Anthem ED claims during 2016, compared to male-specific codes, which accounted for less than 1 percent); and, 20 percent of claims would be denied for nonwhite patients when this demographic group represents 16 percent of the state’s nonelderly population with health insurance.

There has been significant media attention to the Anthem policy at the state and national levels. Missouri is leading efforts to expose this policy as unfair, and potentially harmful, to patients. And, efforts to strengthen Missouri’s standard to keep insurers from using coverage determinations as a blunt instrument to manage ED utilization are gaining momentum.

Other states are reacting differently. Some provider groups are choosing to sue Anthem — over the ED issue, as well as concerns related to their policy limiting inpatient imaging services. We’ll be watching these suits as they progress.

As is common for legislation moving late in the session, the bill gained additional heft by amendment in committee. This was the product of Senate-convened negotiations between providers and insurers. In addition to the Anthem issue, SB 982 now includes language on “surprise billing” from out-of-network providers who deliver care in an in-network facility. The new components would set up a structure for provider-insurance carrier negotiations and arbitration, and limit consumer exposure to cost sharing established in their policy. Also, the bill calls for insurers to issue payments to out-of-network providers rather than patients. Several other bills related to Anthem were filed, but few are moving — a bad sign for them this late in session.

Many others and I firmly believe that coordinated care is better than uncoordinated care. That’s where hospitals, physicians and other clinicians, and insurance companies work together as a team to advance health care’s triple aim. Until we find that opportunity, seeking clarity to this policy from the state legislature is important for patients. Anthem is sending dangerous signals with the ED policy, and there is very real potential for patient harm.

I’ve worked in health care policy for most of my adult life. However, I’d feel ill-prepared to self-diagnose in an emergency. I don’t cut my own hair either.

PS. — Last week, I shared information on action taken by the Senate Appropriations committee to provide fairness and equity in Medicaid payments for hospitals. Recall that the House package calls for cuts of $106 million in hospital outpatient payments. The issue now is before a House/Senate conference committee to hammer out the differences between the two legislative proposals. We issued an ALERT this week to all hospitals, personal membership groups, auxilians and our social media network for all to contact their legislators urging support of the Senate stance on Medicaid hospital payments. Action now is critical — take time to make a call or send an email to your legislator about a fair and equitable Medicaid budget.

P.P.S. — Earlier this week, the State Board of Registration for the Healing Arts, which licenses physicians and other practitioners, and the State Board of Nursing issued physician and nursing emergency rules expanding the standards for geographic proximity of an advanced practice registered nurse and a collaborating physician. This is great news. Currently, the maximum distance is 30 miles by road, with 50 miles allowed in federally-designated health professional shortage areas.

The emergency rule is time-limited, but a standard rulemaking process will follow. We’ll be advocating to make the emergency provision permanent. Extending the distance limit will help hospitals extend their reach into communities throughout the state.

I’m always interested in what you think. Send me a note to let me know.

CDC Extends Deadline For Completing NHSN Agreement To Participate And Consent Form

The deadline to complete the online National Healthcare Safety Network Agreement to Participate and Consent form has been extended to Friday, June 15, by the Centers for Disease and Control Prevention. The new deadline applies to all facilities reporting data to NHSN, including those for the following Centers for Medicare & Medicaid Services programs.

Hospital Inpatient Quality Reporting

Hospital Outpatient Quality Reporting

Ambulatory Surgical Center Quality Reporting

Inpatient Psychiatric Facility Quality Reporting

End Stage Renal Disease Quality Incentive

Long-Term Care Hospital Quality Reporting

Inpatient Rehabilitation Facility Quality Reporting

CMS quality reporting deadlines are not affected by the extension. Access to NHSN will be temporarily suspended if the consent form is not completed by the deadline.

Consider This ...

In 2015, roughly 920,000 people between the ages of 25 to 54 were absent from the workforce because they were dependent on opioid drugs, a number that grew each year between 1999 and 2015. More work hours were lost for women — 6.4 billion — than men, who were down 5.7 billion hours from 1999 to 2015.